Original Contribution

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1 Original Contribution CARE DELIVERY ReCAPs (Research Contributions Abbreviated for Print) provide a structured, one-page summary of each paper highlighting the main findings and significance of the work. The full version of the article is available online at jop.ascopubs.org. University of Michigan; Ann Arbor VA Healthcare System, Ann Arbor, MI; and University of Colorado Cancer Center, Denver, CO Corresponding author: Christine Veenstra, MD, MSHP, 300 North Ingalls, NIB, Room 3A22, Ann Arbor, MI 48109; cveenstr@med.umich.edu. Disclosures provided by the authors are available with this article at jop.ascopubs.org. DOI: ; published online ahead of print at jop.ascopubs.org on September 7, Long-Term Economic and Employment Outcomes Among Partners of Women With Early-Stage Breast Cancer Christine M. Veenstra, Lauren P. Wallner, Reshma Jagsi, Paul Abrahamse, Jennifer J. Griggs, Cathy J. Bradley, and Sarah T. Hawley QUESTION ASKED: What are the long-term economic and employment outcomes faced by partners of women with breast cancer? SUMMARY ANSWER: One third of partners reported worse financial status because of patients breast cancers, though most remained working 4 years after diagnosis. Decrease in work hours was common, as was job lock (staying at work to maintain health insurance). WHAT WE DID: Women with nonmetastatic breast cancer reported to Detroit and Los Angeles SEER registries between June 2005 and February 2007 were surveyed both 9 months and 4 years after diagnoses. Partners were surveyed 4 years after the patients diagnoses. Partners were asked about employment and financial impacts of patients breast cancer diagnoses and treatments. WHAT WE FOUND: A total of 517 (67%) of 774 eligible partners completed the survey. Two hundred forty nonretired partners worked during the year after the patients diagnoses; 90% were still working 4 years after diagnosis. A total of 32% decreased work hours because of patients breast cancer diagnoses and treatments; 64% reported that it was very/ extremely important to keep working to keep health insurance. Partners who reported a greater financial burden had a significantly lower emotional quality of life. BIAS, CONFOUNDING FACTOR(S), REAL- LIFE IMPLICATIONS: This study spanned a period of economic recession, which may have accentuated partners negative perceptions of employment and financial status. We cannot be certain that job loss was due to breast cancer and not to national trends in job loss during the study period. As with all survey studies, nonresponse bias and recall bias are possible. The inclusion of a noncancer control group was beyond the study s scope.however, the study attempted to address this by asking partners their perceptions of their economic status as a result of patients breast cancer diagnoses and treatments. To our knowledge, this is the first study to present the perspectives of partners of breast cancer patients about the long-term economic impact of cancer, including the impact on their own employment. We included a large number of partners from two vulnerable subgroups Hispanics and those of low socioeconomic status. It is important that clinicians recognize those patients and partners at risk for job loss, loss of income, and financial burden after a cancer diagnosis. Clinicians should ask about financial concerns early and should include partners in these discussions. This study also suggests that the need for partners to maintain insurance during and after serious illness is critical. As insurance options in the United States continue to evolve, it will become even more important to understand the role of partners insurance and employment options in the face of a cancer diagnosis and for clinicians to recognize not only who is at risk for job loss but also the complex reasons partners may continue to work. 754 Volume 13 / Issue 11 / November 2017 n Journal of Oncology Practice Copyright 2017 by American Society of Clinical Oncology

2 Original Contribution CARE DELIVERY Long-Term Economic and Employment Outcomes Among Partners of Women With Early-Stage Breast Cancer Christine M. Veenstra, Lauren P. Wallner, Reshma Jagsi, Paul Abrahamse, Jennifer J. Griggs, Cathy J. Bradley, and Sarah T. Hawley University of Michigan; Ann Arbor VA Healthcare System, Ann Arbor, MI; and University of Colorado Cancer Center, Denver, CO ASSOCIATED CONTENT Appendix available online Abstract Purpose Work loss is one of many personal costs for patients with cancer and their families. Many women with breast cancer face long-term job loss that stems from their diagnoses. However, little is known about the economic and employment outcomes of partners of women with breast cancer. Methods Women with nonmetastatic breast cancer identified by the Detroit and Los Angeles SEER registries between June 2005 and February 2007 were surveyed at both 9 months and 4 years after diagnosis. Partners were surveyed 4 years after patients diagnoses. Nonretired partners were asked about employment and financial consequences that stemmed from the patients breast cancer diagnoses and treatments. Results A total of 517 (67%) of 774 eligible partners completed the survey; 32% reported worsened financial status attributed to patients breast cancers. Two hundred forty nonretired partners worked during the year after the patients diagnoses; 90% were still working 4 years postdiagnosis. A total of 32% of partners decreased their work hours as a result of patients breast cancer diagnoses and treatments; 64% of partners reported that, as a result of patients breast cancer diagnoses and treatments, it was very/extremely important to keep working to keep health insurance. Overall, 51% of partners reported that it was very/extremely important to avoid changing jobs, because they were worried about loss of health insurance. Conclusion Nearly one third of partners reported that their financial status was worse because of the patient s breast cancer, although most remained working 4 years after a diagnosis. Partners may continue to work longer than desired to compensate for a loss of financial resources in the family. DOI: ; published online ahead of print at jop.ascopubs.org on September 7, INTRODUCTION At least 50% of invasive breast cancer diagnoses occur in working-age women. 1 Treatment of breast cancer can be challenging and time consuming it often spans 9 months or more. Patients and their families can face substantial, sometimes devastating, economic hardship as a result e916 Volume 13 / Issue 11 / November 2017 n Journal of Oncology Practice Copyright 2017 by American Society of Clinical Oncology

3 Economic Outcomes Among Partners of Patients With Breast Cancer of diagnosis and treatment. Work loss and potential loss of employer-provided health insurance are common among patients with cancer. 2-6 Previous studies report short- and long-term work loss amongwomenwithbreastcancer, 6-10 and up to 30% of women who were working at diagnosis report unemployment 4 years later; unemployment rates are even higher among women who received chemotherapy. 4 Cancer and its treatment affect other family members and partners. Partners may take on new caregiving responsibilities that lessen the time they can devote to paid employment. 11,12 Patients who were working before diagnosis may exit the workforce altogether, which leaves the partners employment as the only source of income and health insurance. 13,14 Little is known about the impact of cancer on partners longterm financial and employment outcomes. We are aware of only one study that specifically addresses employment effects of breast cancer diagnosis on partners. By using data collected from patients about their partners employment status and work hours, Bradley and Dahman found that partners of women with breast cancer were more likely to decrease work hours than were working men in a control group. After the active treatment period, men returned to work at their usual level. 15 Partners themselves were not interviewed. We collected information from partners about long-term economic and employment impacts of patients breast cancer with data from a longitudinal, population-based study of women with early-stage breast cancer and their partners. We describe partners perceptions of economic and employment effects, report associations with long-term job retention among partners who were working in the year after the patients diagnoses, and investigate associations between the partners quality of life and perceived financial burden. METHODS Study Population and Data Collection Women age 20 to 79 years, diagnosed with ductal carcinoma in situ or invasive breast cancer between June 2005 and February 2007, whose data were reported to the SEER registries of Los Angeles and Detroit and their partners were eligible. Black and Hispanic women were oversampled in Los Angeles to ensure sufficient representation. In total, 3,252 women were surveyed 9 months after diagnosis (2,290 [73.1%] completed the survey) and again 4 years after diagnosis (1,536 [67.7%] completed the survey). Details of both surveys have been published. 16,17 For the partner survey, 774 women who reported being married/living with partner at both 9 months and 4 years after diagnosis were asked to give a survey packet to their partners between October 2010 and February The partner packet included an introductory letter, a survey, and a $10 cash gift. With a modified Dillman method, which involved mixed survey modes and reminders to optimize survey completion, partners (67%) completed the survey. Partners were surveyed at one time point only, 4 years after diagnosis. Details have been published. 16 The final sample included 510 partners with paired patient-partner employment data. The exclusion of working patients older than age 65 years or the 5% of patients who developed disease recurrence did not significantly change results. Thus, their data are included. The study flow diagram is shown in Appendix Figure A1 (online only). All study protocols were approved by the institutional review boards of the University of Michigan, the University of Southern California, and Wayne State University. Measures Primary outcome variables A modified stress coping framework to assess the impact of cancer on families guided the study. 19 To measure perceptions of long-term financial burden among all partners (n = 510), we asked each partner whether, since the patient s diagnosis, he or she was worse off with regard to health insurance, employment status, and financial status (yes/no for each). Among nonretired partners (n = 240), job retention was measured by selecting partners who reported that they had worked for pay in the first year after the patient s diagnosis and also reported working for pay at the time they completed the survey (4 years after diagnosis). We measured partners perceptions of the impact on their employment by asking whether, as a result of the patient s cancer, they increased or decreased work hours, found work to be a welcome source of support, or quit/lost their job (yes/no for each). We also asked partners how important it was, in the first year after diagnosis, to avoid changing jobs, keep working, or get a new job to maintain or get health insurance (5-point scale from not at all important to extremely important). Finally, we measured partners emotional quality of life with a modified version of the 12-item short form health survey (SF-12), version 2, a well-validated measure of healthrelated quality of life. 20,21 Copyright 2017 by American Society of Clinical Oncology Volume 13 / Issue 11 / November 2017 n jop.ascopubs.org e917

4 Veenstra et al Independent variables Both partner- and patient-level independent variables were considered. Partner-reported independent variables included age (, 65 v $ 65 years), comorbid conditions (0 v $ 1), race/ ethnicity (white/other, black, Hispanic), and educational attainment (high school or less, some college or more). Partnerreported data on household income 4 years after diagnosis, but not at the time of diagnosis, were collected. Given the potential for change in income during the 4 years, this variable was not included in final analyses. The inclusion of a variable to indicate the number of people supported by household income did not significantly change results and was omitted from final analyses. Patient-reported independent variables included age at diagnosis, surgery (lumpectomy v mastectomy), receipt of chemotherapy, and patient employment status at diagnosis. Cancer stage was obtained from patients SEER records. Analysis also was controlled for geographic site (Los Angeles v Detroit). Statistical Methods Analyses wereconducted intwo parts. First,sociodemographic characteristics and long-term financial burden of the entire partner sample were described. Second, job retention and employment impacts were examined in an analytic sample limitedto240partnerswhoworkedforpayinthefirstyearafter the patient s diagnosis and did not report their employment status 4 years after diagnosis as retired. Among the entire partner sample, descriptive statistics weregeneratedfortheoutcomeofperceivedfinancialburden, which consisted of three elements: worse off with regard to health insurance, employment status, and financial status. Bivariable associations were evaluated with x 2 tests between each element of financial burden and the independent variables. A multivariable logistic regression model was estimated to predict adjusted financial burden but control for patient- and partner-level covariates by using Wald F tests. The same procedure was used to estimate the likelihood of job retention among partners who worked for pay after the diagnosis. Three exploratory analyses were performed: dyadic job retention among vulnerable subgroups, partner perceptions of financial status stratified by corresponding patient employment status, and associations between partner quality of life and perceived financial burden. Bivariable associations were evaluated with x 2 tests between the first two exploratory outcomes and the independent variables. A multivariable logistic regression model was estimated to predict partners quality of life but control for perceived financial burden and other patient- and partner-level covariates by using Wald F tests. All statistical tests were two sided; P values,.05 were considered significant. Analyses were conducted with SAS 9.4 (SAS Institute, Cary, NC). RESULTS Of the 774 eligible partners, 510 (66%) completed the survey. Mostwerewhite,youngerthan65yearsofage,andhadatleast some college education (Table 1). Although partners were not specifically asked about their sex, the majority (95%) were married and most likely men. Sixty-four percent of partners worked for pay during the first year after the patients diagnoses; 49% of partners were working for pay 4 years later. Perceptions of Financial Burden As a result of patients cancers, partners reported that they were worse off with regard to health insurance (20%), employment status (19%), and financial status (32%). Among all partners, 19% reported feeling worse off with regard to at least two of these three elements of financial burden. Bivariable analyses of these three elements among the entire partner sample (n = 510) are listed in Table 2. Hispanic partners were significantly more likely to report worse health insurance, employment status, and financial status (all P,.05). Age younger than 65 years was associated with worse health insurance and financial statuses (both P,.05). Lower educational attainment was associated with worse employment status, and patient receipt of chemotherapy was associated with worse financial status (both P,.05). After adjustment for partner- and patient-related covariates, age younger than 65 years was significantly associated with worse health insurance (P =.03), employment status (P =.04), and financial status (P,.01). Patients employment statuses also were significantly associated with partners financial statuses: 48% of partners reported worse financial status if the patient was working before diagnosis but stopped working after diagnosis compared with 40% of partners if the patient did not work before or after diagnosis and 22% of partners if the patient was working before diagnosis and continued to work 4 years later (P,.01 for the three-way comparison between partner financial status stratified by the three different patient work groups: patient e918 Volume 13 / Issue 11 / November 2017 n Journal of Oncology Practice Copyright 2017 by American Society of Clinical Oncology

5 Economic Outcomes Among Partners of Patients With Breast Cancer Table 1. Characteristics of Partner and Patient Sample Characteristic All (n = 510) No. (%) of Partners Working, Nonretired (n = 240) Nonworking, Retired (n = 270) No. (%) of Patients (n = 510) Age, years Mean Range , (57) 212 (88) 80 (30) 400 (78) $ (43) 28 (12) 190 (70) 110 (22) No. of comorbid conditions 0 96 (19) 62 (26) 34 (13) 228 (45) $ (81) 178 (74) 236 (87) 282 (55) Ethnicity White or other 323 (63) 152 (63) 171 (63) 314 (62) Black 64 (13) 24 (10) 40 (15) 63 (12) Hispanic 123 (24) 64 (27) 59 (22) 133 (26) Education High school or less 153 (30) 57 (24) 96 (36) 161 (32) Some college or more 351 (70) 183 (76) 168 (64) 345 (68) Geographic site Los Angeles 252 (49) 122 (51) 130 (48) 252 (49) Detroit 258 (51) 118 (49) 140 (52) 258 (51) Patient disease stage NA NA NA (25) I 200 (39) II 138 (27) III 46 (9) Patient surgical procedure NA NA NA Lumpectomy 341 (67) Mastectomy 169 (33) Patient receipt of chemotherapy NA NA NA No 271 (54) Yes 229 (46) Patient working before diagnosis NA NA NA No 295 (59) Yes 206 (41) NOTE. Total number in each column may not add up because of missing data. Percentages may not add to 100% because of rounding. All partner- and patientrelated covariates were collected 4 years after diagnosis. Abbreviation: NA, not applicable. worked before diagnosis then stopped, patient never worked, patient worked before and after diagnosis). Job Retention Of nonretired partners who worked in the year after the patients diagnoses, 10% were no longer working 4 years after diagnosis. Bivariable correlates of job retention for nonretired, working partners (n = 240) are listed in Table 3. Hispanic partners were significantly less likely to retain jobs, as were partners with less education (both P #.01). After adjustment for partner- and patient-related covariates, education was associated with job retention. Partners with some college or more were significantly more likely to retainjobsthanthosewithhighschoolorless(p =.02; Table 3). In an exploratory analysis among dyads in which both patient and partner were working at diagnosis (n = 181), 24% of patients Copyright 2017 by American Society of Clinical Oncology Volume 13 / Issue 11 / November 2017 n jop.ascopubs.org e919

6 Veenstra et al Table 2. Bivariable Analyses of the Three Elements of Financial Burden, Among Entire Partner Sample No. (%) Worse Off by Element* No. of Partners With Yes Response by Characteristic* Health Insurance Employment Status Financial Status Age, years, (23) 59 (21) 96 (34) $ (14) 31 (14) 45 (21) No. of comorbid conditions 0 17 (18) 16 (17) 22 (23) $ 1 80 (20) 74 (18) 119 (29) Ethnicity White/other 51 (16) 39 (13) 72 (23) Black 14 (22) 13 (20) 19 (30) Hispanic 32 (26) 38 (32) 50 (41) Education High school or less 37 (25) 35 (24) 48 (32) Some college or more 60 (17) 55 (16) 93 (27) Employment Yes 16 (22) 16 (22) 22 (30) No 82 (19) 74 (18) 119 (28) Geographic site Los Angeles 53 (21) 59 (24) 90 (36) Detroit 44 (17) 31 (12) 51 (20) Patient disease stage 0 22 (18) 16 (13) 21 (17) I 37 (19) 37 (19) 58 (30) II 23 (17) 22 (16) 44 (33) III 14 (31) 15 (33) 17 (37) Patient surgical procedure Lumpectomy 59 (18) 52 (16) 85 (26) Mastectomy 38 (23) 38 (23) 56 (34) Patient receipt of chemotherapy No 43 (16) 40 (15) 53 (20) Yes 50 (22) 47 (21) 84 (38) Patient working before diagnosis No 37 (18) 50 (18) 82 (29) Yes 59 (20) 39 (19) 58 (28) NOTE. Responders include working andnonworkingpartners (n = 510). Partners perceptions of the three elementsof financial burden wereascertainedwiththe question stem Since your spouse/partner s breast cancer diagnosis, are you worse off regarding a) health insurance? b) employment status? c) financial status? (all yes/no response). *No. (%) data reflect those who responded yes to the elements of the question stem. P,.05. All other P values were nonsignificant. stoppedworkingafterdiagnosis,whereastheirpartnerscontinuedto work 4 years later. This finding was significant among Hispanic partners and partners with less than high school education(both P,.01). Furthermore, although it was rare for both patient and partner to stop working, job loss for both was significant among Hispanic and less educated partners (both P,.01). Partners Perceptions of Employment Impact Thirty-two percent of partners decreased work hours as a result of the patients cancers, whereas 50% reported that work was a welcome source of support. Sixty-four percent of partners reported that it was very/extremely important to keep working to keep health insurance; 51% reported that it was very/ e920 Volume 13 / Issue 11 / November 2017 n Journal of Oncology Practice Copyright 2017 by American Society of Clinical Oncology

7 Economic Outcomes Among Partners of Patients With Breast Cancer Table 3. Bivariable and Multivariable Analyses of Job Retention Among Nonretired Partners Who Worked During the First Year After the Patient s Diagnosis Characteristic Unadjusted Analyses Odds Ratio (95% CI) P Adjusted Analyses Odds Ratio (95% CI) P Partner variable Age, years.83.95, (Reference) 1.00 (Reference) $ (0.24 to 3.13) 0.96 (0.24 to 3.82) No. of comorbid conditions (Reference) 1.00 (Reference) $ (0.28 to 2.20) 0.54 (0.17 to 1.67) Ethnicity White/other 1.00 (Reference) 1.00 (Reference) Black 1.45 (0.18 to 11.97) 1.18 (0.13 to 10.32) Hispanic 0.25 (0.10 to 0.61) 0.44 (0.14 to 1.34) Education, High school or less 1.00 (Reference) 1.00 (Reference) Some college or more 5.11 (2.10 to 12.43) 3.50 (1.20 to 10.23) Patient variable Patient disease stage (Reference) 1.00 (Reference) I 0.22 (0.05 to 1.02) 0.33 (0.07 to 1.59) II 0.67 (0.12 to 3.78) 0.90 (0.15 to 5.44) III 0.24 (0.04 to 1.38) 0.45 (0.07 to 3.08) Patient working before diagnosis No 1.00 (Reference) 1.00 (Reference) Yes 2.04 (0.81 to 5.11) 2.08 (0.75 to 5.73) NOTE. No. of nonretired partners = 240. Multivariable models that included patient surgical procedure and patient receipt of chemotherapy were not significantly different than multivariable models that omitted these variables, which were not significantly associated with the outcome of job retention. Results of the multivariable model that omitted these variables are shown here. extremely important to avoid changing jobs because they were worried about loss of health insurance. Few partners (13%) reported that it was very/extremely important to get a new job to obtain health insurance. In an exploratory analysis stratified by patients employment statuses before diagnoses, partners were significantly more likely to report that it was very/extremely important to keep working to keep health insurance if the patient was not working compared with partners coupled with working patients (70% v 60%; P =.013). Partners Quality of Life In unadjusted analyses, partners who reported at least two of the three elements of financial burden had significantly lower emotional quality of life scores than those who reported no elements or one element of financial burden (47.9 v 52.9; P,.01). After adjustment for partners perceived financial burdens and the other partner- and patient-related covariates, partners with greater perceived financial burdens had a 3.6-point lower mean quality-of-life score (P,.01), which corresponded to a 0.36 to 0.38 effect size, a medium difference in the SF-12 scoring rubric. DISCUSSION To our knowledge, this is the first study to present perspectives of partners of breast cancer patients about the long-term economic impact of the diagnosis and treatment, including impact on their own employment. We performed a population-based, longitudinal survey of a unique sample of patients with breast cancer and their partners, and it included a large number of partners from two vulnerable subgroups Hispanics and those with low educational attainment. Nearly one third of partners of women with early-stage breast cancer reported worse financial status after patients Copyright 2017 by American Society of Clinical Oncology Volume 13 / Issue 11 / November 2017 n jop.ascopubs.org e921

8 Veenstra et al diagnoses and treatments; one fifth reported worse health insurance status. Most partners who were initially working remained working. This finding is consistent with other studies that showed that husbands do not lose their jobs after patients diagnoses. 15,22 One third of partners decreased work hours, a potential mechanism for feeling worse off financially despite high job retention. This is in line with a prior study, in which survivors of multiple cancers reported that 25% of their informal caregivers made employment changes, including changes toworkhours. 23 Interestingly, othershavefound among survivors of multiple cancers that partners did not substantially change work hours. 22 Perhaps partners in this study, who predominantly were married men, played a caregiving role that reduced the time they could devote to paid work. We also found that partners of patients who lost their jobs more often reported being worse off financially, which suggests that these families were reliant on two incomes before the cancer diagnosis. Perhaps some partners continue to work longer than desired to compensate for such loss in family earnings. Furthermore, we found that, although patient employment status was not significantly associated with job retention among partners, it was associated with financial status. Partners were significantly more likely to report worse perceived financial status if the patient stopped working after diagnosis than if the patient kept working after diagnosis or if the patient never worked at all. In addition, health care costs associated with cancer diagnosis and treatment may increase costs of living and may partially explain the findings that partners reported worse financial status despite job retention. Importantly, partners with high perceived financial burdens had significantly lower emotional quality of life scores, which underscores financial burden as a meaningful outcome among partners. It is important that clinicians recognize patients and partners who are at risk for job loss and financial burden after a cancer diagnosis. We encourage clinicians to ask about employment and insurance concerns early, during the first few appointments, and to include partners in these discussions. Given the findings of this study, clinicians also should be aware of the potential for financial and employment concerns years after a cancer diagnosis and should maintain ongoing discussions with patients and partners. Clinicians may offer to speak with or write letters to employers on behalf of both patients and partners. Importantly, clinicians should be aware of available resources, such as financial counselors and social workers, and should offer referrals for patients and partners. Despite generally high rates of job retention among partners, there were vulnerable subgroups those with low educational attainment and those of Hispanic ethnicity who were less likely to retain their jobs 4 years after patients breast cancer diagnoses. These results are consistent with those of other studies that have found that Hispanic patients with breast cancer and patients with colon cancer who had low socioeconomic statuses were most vulnerable to job loss relative to their counterparts. 5,7 The findings in this study may be relevant to partners of patients with cancers other than breast cancer and could inform studies of partners of patients with other cancers as well. Subgroup analyses showed significant trends toward the worst outcomes in vulnerable groups. For instance, it was more likely that patients stopped working after diagnosis while partners continued to work, or that both patients and partners stopped working after diagnosis, among couples with Hispanic or less educated partners. If both patients with breast cancer and their partners in these vulnerable groups face job loss, the economic impact of breast cancer may be particularly devastating for these families. Additional financial and policyrelated supports both during and after cancer treatment may be needed for such populations. Half of working partners reported that work was a welcome source of support, which suggests that maintenance of employment is important for partners quality of life and that partners continue to work for more than just financial reasons. However, this study also suggests that insurance plays a substantial role in partners employment decisions. Nearly two thirds of partners reported that it was very/extremely important to keep working to maintain health insurance. The responsibility for maintenance of insurance during and after a serious illness may fall on the partner, especially if patients are no longer able to work, and is another potential mechanism for the high rate of long-term job retention among partners in this study. As insurance options in the United States continue to evolve, it will become even more important to understand the role of partners employment in the face of a cancer diagnosis and for clinicians to recognize not only who is at risk for job loss but also the complex reasons that partners may continue to work. This study had several strengths, including collaboration with SEER to deliver surveys to partners, a large and diverse sample of patients and partners, strong survey methods, and the inclusion of the partners voices, but we acknowledge some limitations. Results were obtained from patients with e922 Volume 13 / Issue 11 / November 2017 n Journal of Oncology Practice Copyright 2017 by American Society of Clinical Oncology

9 Economic Outcomes Among Partners of Patients With Breast Cancer nonmetastatic disease in two large metropolitan areas and may not be generalizable to all partners, particularly those in nonurban areas. The study spanned a period of national economic recession, which may have accentuated partners negative perceptions of employment and financial statuses. We cannot be certain that job loss among partners was due to cancer and not to national trends in job loss during the study period. Partners were not specifically asked about how many hours per week they increased or decreased their work hours. Nonresponse bias is possible. When compared with patients whose partners responded to the survey, patients whose partners did not respond were more likely to be black and to have lower educational attainment. Recall bias is possible; partners responded 4 years after the patients diagnoses but were asked some questions related to employment in the year after diagnosis. The exclusion of retired partners from analyses of job retention may have excluded some partners who retired earlier than desired as a result of patients cancers and thus may have underestimated negative employment impacts on partners. The inclusion of a noncancer control group was beyond the scope of this study. However, we attempted to address the association of patients cancer and partners employment and financial status by asking partners about their perceptions of their economic statuses as a result of patients cancer. In conclusion, a substantial proportion of partners of women with breast cancer reported worse financial status. Long-term job retention was high among partners, with the exception of a subgroup of vulnerable partners that included Hispanics and those with low educational attainment. Work was a welcome source of support for many partners, though concerns about maintenance of insurance or compensation for a loss of financial resources within the family also may compel partners to stay in their jobs. Oncology and primary care providers should include partners in discussions of economic and employment concerns about a cancer diagnosis in early clinical encounters and should maintain ongoing discussions of these concerns, which can persist for years after a cancer diagnosis. Acknowledgment Supported by Grants No. R01 CA and R from the National Cancer Institute to the University of Michigan; by a University of Michigan Cansort pilot and feasibility grant (to C.M.V.); and by Grant No. K07 CA from the National Cancer Institute (to C.M.V.). Presented in part at the American Society of Clinical Oncology Quality Care Symposium, Phoenix, AZ, February 26-27, Authors Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org. Author Contributions Conception and design: Christine M. Veenstra, Lauren P. Wallner, Reshma Jagsi, Jennifer J. Griggs, Cathy J. Bradley, Sarah T. Hawley Collection and assembly of data: Paul Abrahamse, Sarah T. Hawley Data analysis and interpretation: All authors Financial support: Sarah T. Hawley Manuscript writing: All authors Final approval of manuscript: All authors Accountable for all aspects of the work: All authors Corresponding author: Christine Veenstra, MD, MSHP, 300 North Ingalls, NIB, Room 3A22, Ann Arbor, MI 48109; cveenstr@med.umich.edu. References 1. American Cancer Society: Breast cancer facts & figures, Atlanta, GA, American Cancer Society, Jeon SH: The long-term effects of cancer on employment and earnings. Health Econ 26: , Zajacova A, Dowd JB, Schoeni RF, et al: Employment and income losses among cancer survivors: Estimates from a national longitudinal survey of American families. Cancer 121: , Jagsi R, Hawley ST, Abrahamse P, et al: Impact of adjuvant chemotherapy on longterm employment of survivors of early-stage breast cancer. Cancer 120: , Veenstra CM, Regenbogen SE, Hawley ST, et al: Association of paid sick leave with job retention and financial burden among working patients with colorectal cancer. JAMA 314: , de Boer AG, Taskila T, Ojajärvi A, et al: Cancer survivors and unemployment: A meta-analysis and meta-regression. JAMA 301: , Mujahid MS, Janz NK, Hawley ST, et al: Racial/ethnic differences in job loss for women with breast cancer. J Cancer Surviv 5: , Bradley CJ, Neumark D, Bednarek HL, et al: Short-term effects of breast cancer on labor market attachment: Results from a longitudinal study. J Health Econ 24: , Bradley CJ, Bednarek HL, Neumark D: Breast cancer and women s labor supply. Health Serv Res 37: , Blinder V, Patil S, Eberle C, et al: Early predictors of not returning to work in lowincome breast cancer survivors: A 5-year longitudinal study. Breast Cancer Res Treat 140: , Yabroff KR, Kim Y: Time costs associated with informal caregiving for cancer survivors. Cancer 115: , Grunfeld E, Coyle D, Whelan T, et al: Family caregiver burden: Results of a longitudinal study of breast cancer patients and their principal caregivers. CMAJ 170: , Bradley CJ, Neumark D, Luo Z, et al: Employment-contingent health insurance, illness, and labor supply of women: Evidence from married women with breast cancer. Health Econ 16: , Lauzier S, Maunsell E, Drolet M, et al: Wage losses in the year after breast cancer: Extent and determinants among Canadian women. J Natl Cancer Inst 100: , Bradley CJ, Dahman B: Time away from work: Employed husbands of women treated for breast cancer. J Cancer Surviv 7: , Lillie SE, Janz NK, Friese CR, et al: Racial and ethnic variation in partner perspectives about the breast cancer treatment decision-making experience. Oncol Nurs Forum 41:13-20, Hawley ST, Griggs JJ, Hamilton AS, et al: Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients. J Natl Cancer Inst 101: , 2009 Copyright 2017 by American Society of Clinical Oncology Volume 13 / Issue 11 / November 2017 n jop.ascopubs.org e923

10 Veenstra et al 18. Dillman DA, Smyth JD, Christian LM, et al: Internet, Mail, and Mixed-Mode Surveys: The Tailored Design Method (ed 3). Hoboken, NJ, Wiley & Sons, Northouse LL, McCorkle R: Spouse caregivers of cancer patients, in J Holland and R McCorkle (eds): Psycho-Oncology (ed 2). New York, NY, Oxford University Press, Ware J Jr, Kosinski M, Keller SD: A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Med Care 34: , Gandek B, Ware JE, Aaronson NK, et al: Cross-validation of item selection and scoring for the SF-12 health survey in nine countries: Results from the IQOLA Project. J Clin Epidemiol 51: , Hollenbeak CS, Short PF, Moran J: The implications of cancer survivorship for spousal employment. J Cancer Surviv 5: , de Moor JS, Dowling EC, Ekwueme DU, et al: Employment implications of informal cancer caregiving. J Cancer Surviv 11:48-57, 2017 e924 Volume 13 / Issue 11 / November 2017 n Journal of Oncology Practice Copyright 2017 by American Society of Clinical Oncology

11 Economic Outcomes Among Partners of Patients With Breast Cancer AUTHORS DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Long-Term Economic and Employment Outcomes Among Partners of Women With Early-Stage Breast Cancer The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO s conflict of interest policy, please refer to or ascopubs.org/jop/site/ifc/journal-policies.html. Christine M. Veenstra Research Funding: Pfizer (Inst) Lauren P. Wallner Research Funding: GlaxoSmithKline (Inst) Reshma Jagsi Employment: University of Michigan Honoraria: International Journal of Radiation Oncology Biology Physics, Institute for Medical Education Consulting or Advisory Role: Eviti Company: Eviti, Baptist Health Research Funding: AbbVie (Inst) Paul Abrahamse No relationship to disclose Jennifer J. Griggs No relationship to disclose Cathy J. Bradley No relationship to disclose Sarah T. Hawley No relationship to disclose Copyright 2017 by American Society of Clinical Oncology Volume 13 / Issue 11 / November 2017 n jop.ascopubs.org e925

12 Veenstra et al Appendix Patients with breast cancer identified (N = 3,252) Patients sent surveys (n = 3,133) Excluded (n = 119) Too ill (n = 59) Denied having cancer (n = 23) Physicians refused to allow patient contact (n = 20) Spoke neither English nor Spanish (n = 17) Nonrespondents (n = 843) Could not be contacted (n = 432) Contacted but no response (n = 411) Completed a baseline survey (time 1; n = 2,290; response rate: 73%) Completed a follow-up survey approximately 4 years after diagnosis (time 2; n = 1,536; response rate: 68%) Could not be merged with SEER data (n = 22) Patients married/living with partner at time 1 and time 2 identified (n = 774); partner survey packets sent to patients and patient asked to give survey to partner Nonrespondents (n = 257) Partners completed surveys (n = 517; response rate: 67%) Partners final analytic sample (n = 510) Were missing employment information (n = 7) Partners did not work in the year after patients diagnosis (n = 181) (Missing work status in year after diagnosis: n = 13) Employed 4 years after diagnosis (n = 8) Not employed 4 years after diagnosis* (n = 173) Unemployed (n = 11) Retired (n = 148) Disabled (n = 19) Partners did work in the year following patients diagnosis Employed 4 years after diagnosis (n = 237) Full time (n = 205) Part time (n = 31) Not employed 4 years after diagnosis* (n = 76) Unemployed (n = 26) Retired (n = 74) Disabled (n = 8) Excluded (n = 76) Retired 4 years after diagnosis (n = 74) Missing employment status at diagnosis (n = 2) Working, nonretired partners included in analyses of job retention (n = 240) Fig A1. Flow of partners into the study, starting with the initial patient sample. (*) Partners could select more than one response. SEER, Surveillance, Epidemiology, and End Results Program e926 Volume 13 / Issue 11 / November 2017 n Journal of Oncology Practice Copyright 2017 by American Society of Clinical Oncology